Cosmetic and Reconstructive Procedures

UnitedHealthcare? Medicare Advantage Coverage Summary

Cosmetic and Reconstructive Procedures

Policy Number: MCS022.02 Approval Date: June 14, 2021

Instructions for Use

Table of Contents

Page

Coverage Guidelines ..................................................................... 1

? General Coverage Guidelines................................................1

Supporting Information ................................................................. 5

Policy History/Revision Information ............................................. 9

Instructions for Use ....................................................................... 9

Related Medicare Advantage Policy Guidelines ? Breast Reconstruction Following Mastectomy (NCD

140.2) ? Cosmetic and Reconstructive Services and

Procedures ? Dermal Injections for the Treatment of Facial

Lipodystrophy Syndrome (LDS) (NCD 250.5) ? Gender Dysphoria and Gender Reassignment

Surgery (NCD 140.9) ? Laser Procedures (NCD 140.5) ? Plastic Surgery to Correct "Moon Face" (NCD 140.4) ? Treatment of Actinic Keratosis (NCD 250.4)

Coverage Guidelines

Cosmetic or reconstructive surgery is covered when Medicare criteria are met.

General Coverage Guidelines

Reconstructive surgery is surgery performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, tumors, or disease. Reconstructive surgery is generally performed to improve function, but may also be done to approximate normal appearance. Refer to multiple LCDs for Cosmetic and Reconstructive Surgery at . (Accessed August 23, 2021)

Cosmetic Surgery is surgery performed to reshape normal structures of the body to improve the patient's appearance and selfesteem. Refer to multiple LCDs for Cosmetic and Reconstructive Surgery at . (Accessed August 23, 2021)

Cosmetic surgery or expenses incurred in connection with such surgery is not covered. Cosmetic surgery is only covered when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose. Refer to the Medicare Benefit Policy Manual, Chapter 16, ?120 ? Cosmetic Surgery. (Accessed August 23, 2021)

Breast Reconstruction

Refer to the Coverage Summary titled Breast Reconstruction Following Mastectomy.

Cosmetic and Reconstructive Procedures

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Breast Reduction Surgery (Reductive Mammoplasty) (CPT code 19318)

Medicare does not have a National Coverage Determination (NCD) for breast reduction (reductive mammoplasty). Local Coverage Determinations (LCDs/Local Coverage Article (LCAs) exist for all states/territories and compliance with these policies is required where applicable. For specific LCDs/LCAs, refer to the table for Breast Reduction (Reductive Mammoplasty).

Blepharoplasty

Refer to the Coverage Summary titled Blepharoplasty and Related Procedures.

Ear Graft (CPT code 21235)

Medicare does not have a National Coverage Determination (NCD) for ear graft. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist.

For coverage guidelines, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Cosmetic and Reconstructive Procedures. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Treatment of Actinic Keratosis;

Destruction of actinic keratosis without restrictions based on lesion or patient characteristics is covered. Refer to the NCD for Treatment of Actinic Keratosis (250.4). (Accessed April 2, 2021)

Panniculectomy/Abdominal Lipectomy (CPT codes 15830, 15847, 15832, 15833, 15834, 15835, 15836, 15837, 15838 and 15839)

Medicare does not have a National Coverage Determination (NCD) for panniculectomy/lipectomy. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist and compliance with these policies is required where applicable. For specific LCDs/LCAs, refer to the table for Panniculectomy/Abdominal Lipectomy.

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Panniculectomy and Body Contouring Procedures. Note: After checking the Panniculectomy/Abdominal Lipectomy table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Suction-Assisted Lipectomy (CPT codes 15876, 15877, 15878 and 15879)

Medicare does not have a National Coverage Determination (NCD) for suction assisted lipectomy. Local Coverage Determinations (LCDs)/Local Coverage Article (LCAs) exist and compliance with these policies is required where applicable. For specific LCDs/LCAs, refer to the table for Suction-Assisted Lipectomy.

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Panniculectomy and Body Contouring Procedures. Note: After checking the Suction-Assisted Lipectomy table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Mastopexy (CPT code 19316)

Medicare does not have a National Coverage Determination (NCD) for mastopexy. Local Coverage Determinations (LCDs)/Local Coverage Article (LCAs) exist and compliance with these policies is required where applicable. For specific LCDs/LCAs, refer to the table for Mastopexy.

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Breast Reconstruction Post Mastectomy and Poland Syndrome. Note: After checking the Mastopexy table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Cosmetic and Reconstructive Procedures

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Note: On July 24, 2019, the Food and Drug Administration (FDA) issued a safety communication related to the voluntary recall of certain Allergan BIOCELL textured breast implants and tissue expanders. For specific information, see the following FDA communication at: %20from%20market&utm_medium=email&utm_source=Eloqua. (Accessed April 2, 2021)

For guidelines on services related to and required as a result of services which are not covered under Medicare. Refer to the Coverage Summary titled Non-Covered Services (Including Services/Complications Related to Non-Covered Services).

Gynecomastia Treatment (CPT code 19300)

Medicare does not have a National Coverage Determination (NCD) for gynecomastia. Local Coverage Determinations (LCDs)/Local Coverage Article (LCAs) exist and compliance with these policies is required where applicable. For specific LCDs/LCAs, refer to the table for Gynecomastia Treatment.

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Gynecomastia Treatment. Note: After checking the Gynecomastia Treatment table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS)

Effective for claims with dates of service on and after March 23, 2010, dermal injections for LDS are only reasonable and necessary using dermal fillers approved by the Food and Drug Administration (FDA) for this purpose, and then only in HIVinfected beneficiaries when LDS caused by antiretroviral HIV treatment is a significant contributor to their depression. Refer to the NCD for Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS) (250.5). (Accessed April 2, 2021)

Tattooing to Correct Color Defects of the Skin (CPT codes 11920, 11921 and 11922)

Medicare does not have a National Coverage Determination (NCD) for tattooing to correct color defects of the skin. Local Coverage Determinations (LCDs)/ Local Coverage Article (LCAs) exist and compliance with this policy is required where applicable. For specific LCDs/LCAs, refer to the table for Tattooing to Correct Color Defects of the Skin.

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Breast Reconstruction Post Mastectomy and Poland Syndrome. Note: After checking the Tattooing to Correct Color Defects of the Skin table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Myocutaneous Flaps for the Head, Neck, Trunk and Extremities (CPT codes 15731, 15733, 15734, 15736, 15738 and 15756)

Medicare does not have an NCD for myocutaneous flaps. Local Coverage Determinations (LCDs)/Local Coverage Article (LCAs) do not exist.

For coverage guidelines, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Cosmetic and Reconstructive Procedures. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

For Myocutaneous Flaps related to Breast Reconstruction (CPT codes 19361, 19364, 19366, 19367, 19368 and 19369), refer to the Coverage Summary titled Breast Reconstruction Following Mastectomy.

Cosmetic and Reconstructive Procedures

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Toe Polydactyly Reconstruction (CPT code 28344)

Medicare does not have an NCD for toe polydactyly reconstruction. Local Coverage Determinations (LCDs)/Local Coverage Article (LCAs) do not exist.

For coverage guidelines, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Cosmetic and Reconstructive Procedures. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Pectus Deformity Repair (CPT codes 21740, 21742 and 21743)

Medicare does not have a National Coverage Determination (NCD) for pectus deformity repair. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist.

For coverage guidelines, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Pectus Deformity Repair. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Septoplasty, Rhinoplasty, Vestibular Stenosis Repair and Balloon Sinuplasty

Refer to the Coverage Summary titled Nasal and Sinus Procedures.

Surgery to Correct Moon Face

The cosmetic surgery exclusion precludes payment for any surgical procedure directed at improving appearance. The condition giving rise to the patient's preoperative appearance is generally not a consideration. The only exception to the exclusion is surgery for the prompt repair of an accidental injury or for the improvement of a malformed body member which coincidentally serves some cosmetic purpose. Since surgery to correct a condition of "moon face" which developed as a side effect of cortisone therapy does not meet the exception to the exclusion, it is not covered under Medicare. Refer to the NCD for Plastic Surgery to Correct "Moon Face" (140.4). (Accessed April 2, 2021)

Gender Dysphoria Treatment

There is an NCD for Gender Dysphoria and Gender Reassignment Surgery (140.9) which states that CMS determined that no NCD is appropriate at this time for gender reassignment surgery for Medicare beneficiaries with gender dysphoria and coverage determination will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis.

Local Coverage Determination (LCD)/Local Coverage Articles (LCAs) exist and compliance with this policy is required where applicable. For specific LCDs/LCAs, refer to the table for Gender Dysphoria Treatment.

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Gender Dysphoria Treatment. Note: After checking the Gender Dysphoria Treatment table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

For other related cosmetic procedures, refer to the applicable guideline(s) on this Coverage Summary; refer to the Index above for the list of these guidelines.

Notes: For guidance on diagnosis and treatment of impotence/erectile dysfunction, refer to Coverage Summary titled Impotence Treatment. Cross sex hormone therapy may be covered as part of gender dysphoria treatment; Part B vs Part D coverage rules also apply. For Part B vs Part D medication coverage guideline, refer to the Coverage Summary titled Medications/Drugs (Outpatient/Part B).

Cosmetic and Reconstructive Procedures

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Light and Laser Therapy for Rosacea and Rhinophyma

Medicare does not have a National Coverage Determination (NCD) for light and laser therapy for rosacea and rhinophyma. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist.

For coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled Light and Laser Therapy. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Insertion of Tissue Expander for Other Than Breast (CPT code 11960)

Medicare does not have an NCD for insertion tissue expander for other than breast. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist.

For coverage guidelines, refer to the UnitedHealthcare Commercial Coverage Determination Guideline titled Cosmetic and Reconstructive Procedures. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

For insertion of tissue expander for breast, refer to the Coverage Summary titled Breast Reconstruction Following Mastectomy.

Supporting Information

Important Note: When searching the Medicare Coverage Database, if no LCD/LCA is found, then use the applicable referenced default policy below for coverage guidelines.

LCD/LCA ID L38914 (A58573)

Breast Reduction (Reductive Mammoplasty)

Accessed October 6, 2021

LCD/LCA Title

Contractor Type

Contractor Name

Cosmetic and

Part A and B MAC First Coast Service

Reconstructive Surgery

Options, Inc.

Applicable States/Territories FL, PR, VI

L35001 (A56837)

Reduction Mammoplasty

Part A and B MAC National Government Services, Inc.

CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

L35163 (A57221)

Plastic Surgery

Part A and B MAC Noridian Healthcare Solutions, LLC

CA, AS, GU, HI, MP, NV

L37020 (A57222)

Plastic Surgery

Part A and B MAC Noridian Healthcare Solutions, LLC

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

L35090 (A56587)

Cosmetic and

Part A and B MAC Novitas Solutions, Inc.

Reconstructive Surgery

AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX

L33428 (A56658)

Cosmetic and

Part A and B MAC

Reconstructive Surgery

Palmetto GBA

AL, GA, NC, SC, TN, VA, WV

L34698 (A57475)

Cosmetic and

Part A MAC

Reconstructive Surgery

Wisconsin Physicians Service Insurance Corporation

AK*, AL*, AR*, AZ*, CA*, CO*, CT*, DE*, FL*, GA*, HI*, IA, ID*, IL*, IN, KS, KY, LA*, MA*, MD*, ME*, MI, MO, MS*, MT*, NC*, ND*, NE, NH*, NJ*, NM*, NV*, OH, OK*, OR*, PA*, RI*, SC*, SD*, TN*, TX*, UT*, VA*, VT*, WA*, WI*, WV*, WY*

(Note: States notated with an asterisk should follow the other

Cosmetic and Reconstructive Procedures

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LCD/LCA ID

LCD/LCA Title

Breast Reduction (Reductive Mammoplasty)

Accessed October 6, 2021

Contractor Type

Contractor Name

L34698 (A57475)

Cosmetic and Reconstructive Surgery

Part B MAC

Wisconsin Physicians Service Insurance Corporation

Back to Guidelines

Applicable States/Territories available state-specific LCD/LCA listed in this table. This WPS LCD/LCA only applies to states without asterisk.)

IA, IN, KS, MI, MO, NE

LCD/LCA ID L38914 (A58573) L35163 (A57221) L37020 (A57222) L35090 (A56587) L33428 (A56658) L34698 (A57475)

LCD/LCA Title Cosmetic and Reconstructive Surgery Plastic Surgery

Plastic Surgery

Cosmetic and Reconstructive Surgery Cosmetic and Reconstructive Surgery Cosmetic and Reconstructive Surgery

Panniculectomy/Abdominal Lipectomy

Accessed October 6, 2021

Contractor Type

Contractor Name

Part A and B MAC First Coast Service

Options, Inc.

Part A and B MAC Noridian Healthcare Solutions, LLC

Part A and B MAC Noridian Healthcare Solutions, LLC

Part A and B MAC Novitas Solutions, Inc.

Part A and B MAC Palmetto GBA

Part A MAC

Wisconsin Physicians Service Insurance Corporation

L34698 (A57475)

Cosmetic and Reconstructive Surgery

Part B MAC

Wisconsin Physicians Service Insurance Corporation

Back to Guidelines

Applicable States/Territories FL, PR, VI

CA, AS, GU, HI, MP, NV

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX

AL, GA, NC, SC, TN, VA, WV

AK*, AL*, AR*, AZ*, CA*, CO*, CT, DE*, FL*, GA*, HI*, IA, ID*, IL, IN, KS, KY, LA*, MA, MD*, ME, MI, MO, MS*, MT*, NC*, ND*, NE, NH, NJ*, NM*, NV*, OH, OK*, OR*, PA*, RI, SC*, SD*, TN*, TX*, UT*, VA*, VT, WA*, WI, WV*, WY* Note: States notated with an asterisk should follow the other available state-specific LCD/LCA listed in this table. This WPS LCD/LCA only applies to states without asterisk. IA, IN, KS, MI, MO, NE

Cosmetic and Reconstructive Procedures

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LCD/LCA ID L35163 (A57221) L37020 (A57222) L34698 (A57475)

LCD/LCA Title Plastic Surgery

Plastic Surgery

Cosmetic and Reconstructive Surgery

Suction-Assisted Lipectomy

Accessed October 6, 2021

Contractor Type

Contractor Name

Part A and B MAC Noridian Healthcare

Solutions, LLC

Part A and B MAC Noridian Healthcare Solutions, LLC

Part A MAC

Wisconsin Physicians Service Insurance Corporation

L34698 (A57475)

Cosmetic and Reconstructive Surgery

Part B MAC

Wisconsin Physicians Service Insurance Corporation

Back to Guidelines

Applicable States/Territories CA, AS, GU, HI, MP, NV

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

AK*, AL, AR, AZ*, CA*, CO, CT, DE, FL, GA, HI*, IA, ID*, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT*, NC, ND*, NE, NH, NJ, NM, NV*, OH, OK, OR*, PA, RI, SC, SD*, TN, TX, UT*, VA, VT, WA*, WI, WV, WY* Note: States notated with an asterisk should follow the other available state-specific LCD/LCA listed in this table. This WPS LCD/LCA only applies to states without asterisk.

IA, IN, KS, MI, MO, NE

LCD/LCA ID L38914 (A58573) L35001 (A56837) L35163 (A57221) L37020 (A57222) L35090 (A56587) L33428 (A56658) L34698 (A57475)

LCD/LCA Title Cosmetic and Reconstructive Surgery Reduction Mammoplasty Plastic Surgery

Plastic Surgery

Cosmetic and Reconstructive Surgery Cosmetic and Reconstructive Surgery Cosmetic and Reconstructive Surgery

Mastopexy

Accessed October 6, 2021

Contractor Type

Contractor Name

Part A and B MAC First Coast Service Options, Inc.

Part A and B MAC National Government Services, Inc.

Part A and B MAC Noridian Healthcare Solutions, LLC

Part A and B MAC Noridian Healthcare Solutions, LLC

Part A and B MAC Novitas Solutions, Inc.

Part A and B MAC Palmetto GBA

Part A MAC

Wisconsin Physicians Service Insurance Corporation

Applicable States/Territories FL, PR, VI

CT, IL, MA, ME, MN, NH, NY, RI, VT, WI AS, CA, GU, HI, MP, NV

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AR, CO, DC, DE, TX, LA, MS, MD, NJ, NM, OK, PA AL, GA, NC, SC, TN, VA, WV

AK*, AL*, AR*, AZ*, CA*, CO*, CT*, DE*, FL, GA*, HI*, IA, ID*, IL*, IN, KS, KY, LA*, MA*, MD*, ME*, MI, MO, MS*, MT*, NC*, ND*, NE, NH*, NJ*, NM*, NV*, OH, OK*, OR*, PA*, RI*, SC*, SD*, TN*, TX*,

Cosmetic and Reconstructive Procedures

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LCD/LCA ID

LCD/LCA Title

Mastopexy

Accessed October 6, 2021

Contractor Type

Contractor Name

L34698 (A57475)

Cosmetic and Reconstructive Surgery

Part B MAC

Wisconsin Physicians Service Insurance Corporation

Back to Guidelines

Applicable States/Territories UT*, VA*, VT*, WA*, WI*, WV*, WY*

Note: States notated with an asterisk should follow the other available state-specific LCD/LCA listed in this table. This WPS LCD/LCA only applies to states without asterisk.

IA, IN, KS, MI, MO, NE

LCD/LCA ID L38914 (A58573) L35163 (A57221) L37020 (A57222) L35090 (A56587) L34698 (A57475)

LCD/LCA Title Cosmetic and Reconstructive Surgery Plastic Surgery

Plastic Surgery

Cosmetic and Reconstructive Surgery Cosmetic and Reconstructive Surgery

Gynecomastia Treatment

Accessed October 6, 2021

Contractor Type

Contractor Name

Part A and B MAC First Coast Service Options, Inc.

Part A and B MAC Noridian Healthcare Solutions, LLC

Part A and B MAC Noridian Healthcare Solutions, LLC

Part A and B MAC Novitas Solutions, Inc.

Part A MAC

Wisconsin Physicians Service Insurance Corporation

L34698 (A57475)

Cosmetic and Reconstructive Surgery

Part B MAC

Wisconsin Physicians Service Insurance Corporation

Back to Guidelines

Applicable States/Territories FL, PR, VI

CA, AS, GU, HI, MP, NV

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

AR, CO, DE, DC, LA, MD, MS, NJ, NM, OK, PA, TX

AK*, AL, AR*, AZ*, CA*, CO*, CT, DE*, FL*, GA, HI*, IA, ID*, IL, IN, KS, KY, LA*, MA, MD*, ME, MI, MO, MS*, MT*, NC, ND*, NE, NH, NJ*, NM*, NV*, OH, OK*, OR*, PA*, RI, SC, SD*, TN, TX*, UT*, VA, VT, WA*, WI, WV, WY* Note: States notated with an asterisk should follow the other available state-specific LCD/LCA listed in this table. This WPS LCD/LCA only applies to states without asterisk. IA, IN, KS, MI, MO, NE

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